Seborrhoeic Dermatitis

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Seborrhoeic Dermatitis (Dandruff) article more useful, or one of our other health articles.

Seborrhoeic Dermatitis

In this article

Seborrhoeic dermatitis (SD) is a common, benign scaling rash. It is named dermatitis because it involves inflammation of the skin and seborrhoeic because it affects areas rich in sebaceous glands. Therefore, it is most common on the face, scalp and chest. It can affect any age from puberty onwards. It occurs in babies in a form known as infantile seborrhoeic dermatitis.

Globally, seborrhoeic dermatitis occurs in 1-5% of the general population. This increases in the immunocompromised, with prevalence rates reported at 34-83%, and it has been suggested that it could be an early marker of HIV infection. In individuals with AIDS, the condition is often severe.

SD is more common in males than in females, which is thought to be due to the effect of androgen on production of sebum. Peak incidence is in infants, in adolescents and in young adults; however, it can occur at any age. It occurs throughout the world.

The exact cause of seborrhoeic dermatitis is unclear but it is probably an inflammatory reaction to yeast called Malassezia spp. This yeast may be a normal skin commensal. Patients with seborrhoeic dermatitis may have a reduced resistance to the yeast.

Symptoms may be aggravated by illness, psychological stress, fatigue, change of season, poor immune function (eg, HIV) and certain medications. These include buspirone, chlorpromazine, cimetidine, griseofulvin, haloperidol, lithium, interferon alfa and methyldopa. It is more common in individuals with neurological conditions such as Parkinson's disease. Immobility (causing sebum to build up) may be a factor in this.

Pityriasis capitis, or 'dandruff', is a non-inflamed form of seborrhoeic dermatitis of the scalp.

The basis of treatment is regular antifungal medication with intermittent topical steroids. There is no evidence of superiority of one antifungal over another[8]. Calcineurin inhibitors are increasingly used in this condition, with evidence of comparable efficacy to azoles when used for the face and scalp[9]. Aims are to improve the appearance of the visible rash and to reduce itch and erythema.

Scalp

First remove thick crusts or scales with olive oil or a keratolytic preparation such as salicylic acid or coal tar. Olive oil should be left on the affected areas for several hours before being washed off with normal or coal tar shampoo.

Medicated shampoos: a shampoo containing ketoconazole 2% (such as Nizoral®) should be used, with selenium sulfide shampoo (such as Selsun®) as an alternative. If these are unacceptable, shampoos containing zinc pyrithione (eg, head & shoulders®), coal tar or salicylic acid may be used. The British National Formulary (BNF) contains a list of preparations with differing strengths of these active ingredients[10].

Shampoos are used twice a week for at least a month, after which the frequency may be reduced.

They may also be used in the beard area.

Steroid scalp applications reduce itching. Intermittent use for a few consecutive days may be helpful. Avoid continuous use. Use a potent topical steroid for the scalp but not in the beard area.

Face, ears, chest and back

Keep the skin clean but avoid soap.

Ketoconazole or another antifungal cream may be used once daily for 2-4 weeks. This can be repeated as necessary. Reduce frequency once symptoms are controlled. Antifungal shampoos may be used as a body wash in addition.

1% hydrocortisone cream can be applied once or twice daily for a week or two. Again, intermittent courses may be required for this chronic condition (and continuous use or high doses should be avoided).

Topical calcineurin inhibitors such as pimecrolimus cream or tacrolimus ointment may be helpful. Evidence suggests these have similar efficacy to steroid creams and antifungal agents[11, 12]. Use of calcineurin inhibitors may allow sparing of steroid use. Topical lithium salts have also been shown to be effective (and possibly more so than antifungal creams) but are not available in the UK[9].

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